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Chapter 11 Diseases of Alimentary Tract Occurrence Cause Mechanism Appearance Pathologic Anatomy Carcinoma of Lip Common in white males (esp. outdoor workers) Occurs b/t 50-70 years old Chronic solar irradiation Sunlight damage to vermillion border of lip (thin, minimally keritanized strat. squam.) Most covers entire lower lip Leukoplakia dry, white, scaly, opaque Dysplasia Begins as small crusting nodule (sore) Lesion enlarges to firm plaque slightly elevated edges, shallow central ulcer covered by adherent crust Primary lesion is 1 cm in diameter Advanced lesion is a large, fungating, deeply invasive, firm-based ulcer Lesion is NOT painful or tender Carcinoma of Mouth More common in men Uncommon 50-80 years old Unknown Predisposing factors: chewing tobacco, dip, smoking tobacco (cigars, pipes), chronic alcoholism Arise from tongue (lateral borders), floor of mouth (invasive), or buccal mucosa (back half of cheek, opposite occlusal level of teeth) Preceded by widespread dysplasia - Velvety red, bluish white, or milk white Lesions are firm masses w/ ulceration Exophytic (fungating mass) or invasive (deeply ulcerated, fissured) Metastases upper cervical lymph nodes

Clinical Features Microscopic Anatomy Treatment

Well-differentiated Squamous Wedge excision Irradiation Lymph node metastases treated by excision (suprahyoid neck dissection) Most pts cured

Local pain (from ulceration & infection) Hypersalivation Immobility of part Cervical lymphadenopathy Well-differentiated Squamous Interstitial irradiation Resection of primary tumor & radial neck dissection pts cured, others die w/in 2 years Secondary bacterial infection Distant metastases Continued widespread oral dysplasia Local infection + hemorrhage + malnutrition Bronchopneumonia

Complications Cause of Death

Tumors of Salivary Glands Occurrence 20-60 years old; common in both sexes Location most frequent in parotid gland; less frequent in submandibular & sublingual glands; least frequent in minor salivary glands Pathologic Anatomy o Most are benign mixed tumors (pleomorphic adenomas) Glandular epithelium + myxoid CT Small, slow-growing, freely moving, painless & firm Treatment excision; most are cured o Some are carcinomas Hard, painful mass Fixed to underlying structures or skin Locally aggressive invaded adjacent tissues, but rarely metastasize Treatment wide resection; recur frequently; often fatal

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Occurrence Cause

Mechanism Appearance

Carcinoma of Esophagus 50-70 years old more frequent in men & blacks Unknown Predisposing Factors smoking tobacco, chronic alcoholism, hiatus hernia w/ gastric acid reflux, chronic iron deficiency Grows slowly Limited local spread Large plaque, fungating mass OR Ulcer w/ firm, ragged base & elevated margins

Carcinoma of Stomach 2nd most common fatal cancer More frequent in older adults & men Unknown Predisposing Factors consumption of smoked, cured, & salted meats/fish (contain polycyclic aromatic compounds) Large (5-10 cm) lesion Penetrating: saucer-shaped, elevated nodule margins Fungating: friable cauliflower mass Diffusely infiltrative: linitis plastica; thickens/hardens all of gastric wall, no distinct mass Most common in pyloric area (near the cardia) Obstruction of stomach Anorexia, nausea, epigastric discomfort/pain, wt. loss Fatigue easily Iron deficiency anemia (lesion oozes blood) Palpable epigastric mass Poorly differentiated Adenocarcinoma Prevention eat more fruits & vegetables Surgery 5 year survival rate (10%) Metastases occur early in regional lymph nodes, peritoneum, & liver Extension into surrounding organs (spleen, pancreas, tcolon, liver) Cachexia Gastric obstruction

Pathologic Anatomy Clinical Features Microscopic Anatomy Treatment Complications

Level of tracheal bifurcation or esophagogastric junction Esophageal obstruction due to intraluminal tumor growth &/or fibrous stricture of wall Progressive dysphagia (difficult swallowing) solid & liquid foods Weight loss Squamous w/ moderate differentiation OR Adenocarcinoma Inoperable when symptoms 1st occur 5 year survival rate (<10%) most die w/in 1 year Metastases to regional lymph nodes Distant metastases (late, not widespread) Cachexia Perforation into tracheobronchial tree w/ severe pneumonia Hemorrhage due to erosion of great vessel

Cause of Death

Gastritis inflammation of gastric mucosa Acute Gastritis Common, transient lesion Cause: ingested irritant (aspirin, food, chemicals) Mucosa is inflamed, multiple shallow ulcers Symptoms: Epigastric pain & tenderness, nausea & emesis, sometimes hematemesis Subsides in 1-several days No sequelae

Chronic Gastritis Asymptomatic or minimal dyspepsia (indigestion) Cause: chronic alcoholism, gastric infection (Helicobacter pylori) May progress to gastric mucosal atrophy w/ gastric anacidity

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Peptic Ulcers Features Location Acute Peptic Ulcers Shallow ulcers Short duration Digestion of alimentary mucosa by gastric juice Stomach, Distal Esophagus, &/or Proximal duodenum Chronic Peptic Ulcers (CPU) Long-standing Occurs in otherwise healthy person Acid-peptic digestion of alimentary tract wall Stomach or duodenum (more common) Occur adjacent to areas of fundic (a-p secreting) gastric mucosa On/near lesser curvature of plyloric part of stomach or in 1st part of duodemum (<2mm from pylorus) Basic cause unknown volume of acid-pepsin in gastric juice Vagal stimulation of stomach s resting & digestive secretion rates

Cause

Impaired vitality of alimentary mucosa &/or excessive secretion of gastric juice

Predisposing Factors

Appearance

Shock w/ systemic hypotension, splanchnic vasoconstriction, & mucosal blood flow Stress Adrenal glucocorticoid use Round, shallow mucosal erosions Hemorrhagic base 5mm diameter, 2 mm deep

Solitary ulcer Deep round or oval Smooth, flat, white base of dense fibrous tissue 1-2 cm diameter penetrates all layers of wall Healing ulcer: puckered, indented mucosa, underlying dense fibrous scar Epigastric pain (1-4 hrs after eating) relieved by ingestion of food/antiacids, aggravated by alcohol & condiments Hemorrhage, perforation, & pyloric obstruction Secondary hyperplasia of fundic glands Medicine or surgery in severity over 5-10 years then recover spontaneously

Clinical Features Complications Treatment

Most unapparent or obscured by primary disease Substernal or epigastric pain & hemorrhage

Gastrointestinal Obstruction mechanical ileus - mechanical obstruction to passage of alimentary contents through the GI tract o partial or complete o involves small intestine more often than large intestine Causes (in descending order of frequency Fibrous Due to prior laparotomy or occurring after any abdominal disease peritoneal Constrict or kink the bowel adhesions Neoplasms Ex: carcinomas or colon & stomach Obstruction due to intraluminal growth OR by annular constriction or internal pressure on stomach/intestine Abdominal Protrusion of an abdominal viscus (usu. a loop of intestine) thru the abdominal wall hernia into a peritoneal pouch obstruction of herniated loop in neck of hernia sack Incarcerated (irreducible) once hernia becomes fixed by adhesions (cant be returned to the abdomen) Ex: inguinal, femoral, umbilical, incisional, diaphragmatic Intussusception Telescoping of a segment of bowel into the next segment of bowel ahead

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o o o

Ileocecel region often involved Usu. occurs in 1st 2 years of life Simple obstruction blood supply of bowel is normal until severe distention develops; intestinal colic w/out abdominal tenderness Strangulation obstruction obstruction + compromise of blood supply to the bowel; causes abdominal tenderness, sometimes abdominal wall rigidity Other types of obstruction (not mechanical): Primary injury of bowel - Intestinal infarction Reflex inhibition of peristalsis occurs in other wise normal bowel; called adynamic ileus Due to acute peritonitis OR Extraperitoneal conditions (UTIs, pneumonia, uremia, spinal cord injury)

Pain

Effects Intestinal colic waves of cramping intermittent abdominal pain; due to hyperperistalsis; accompanied by bowel sounds; may push contents thru obstructed segment Pyloric obstruction epigastric pain; ed by eating, relieved by vomiting Small bowel obstruction midabdominal pain Large bowel obstruction poorly localized pain, usu. in hypogastrum Adynamic ileus peristalsis inhibited; intestinal colic does NOT occur; steady dull pain or no pain @ all; silent abdomen (no bowel sounds) or feeble bowel sounds Vomiting Obstruction of proximal half of GI tract vomiting frequent & copious; Prevents severe distention of bowel; Causes fluid & electrolyte loss Obstruction of distal half vomiting is less marked or absent Distention Occurs w/ both intestinal colic & adynamic ileus Obstructed bowel distended by gas (swallowed air) & fluid (ingested fluid + digestive juices) Prevented by vomiting w/ obstruction of proximal half of GI tract Obstruction of distal half swollen abdomen; can lead to impaired blood flow due to compression of intramural veins, mucosal necrosis, & wet gangrene due to invasion of bowel wall by intraluminal bacteria Infarcts of the Intestine o uncommon, usu. occur in elderly Cause - occlusion of superior mesenteric vessel (by one of the following processes:) Venous Plebitis & resultant venous thrombosis begin in diseased viscus, spread centripetally thrombosis Results in moderately rapid onset of symptoms Arterial From mural thrombus in left ventricle or atrium OR from endocarditic vegetation of embolism mitral or aortic valve Arterial Most frequent cause of mesenteric vascular occlusion thrombosis Usu. due to severe arteriosclerosis of origin & 1st 2 cm of superior mesenteric artery o intestinal infarcts w/out mesenteric vascular occlusion mesenteric arteriosclerosis w/ narrowed (but not occluded) arteries CHF or shock leads to CO infarct Pathologic Anatomy o Involves intestine from beginning of jejunem middle of transverse colon Usu. limited to distal jejunum & ileum by collateral circulation o Hemorrhagic infarct blood from arterial collaterals seeps into dying tissue; hemorrhage of wall & lumen o Wet gangrene intraluminal bacteria (esp. clostridia) invade dying bowel wall; dark purple w/ foul odor Clinical Features

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o Severe, poorly localized midabdominal pain, often colicky o Slight abdominal tenderness w/out rigidity, followed by signs of peritonitis o Shock, vomiting, bloody diarrhea or obstipation, leukocytosis o Usu. fatal due to blood loss & toxic factors from necrotic tissue Idiopathic Inflammatory Bowel Diseases Diseases w/ Known Causes Bacillary dysentery Shigella Amebic dysentery Entamoeba histolytica Typhoid fever Salmonella typhi Campylobacter Campylobacter jejuni enterocolitis Viral gastroenteritis Rotavirus (infants, children) Norwalk (adults) Antibiotic-associated Clostridium defficile colitis Travelers diarrhea Enterotoxigenic strains of E. coli Giardiasis Giardia lamblia Cholera Vibrio cholerae Diseases of Unknown Cause Crohns disease Chronic ulcerative colitis Regional enteritis, segmental enteritis, & transmural Mucosal proctocolitis enterocolitis may be due to cellular autoimmunity (excessive activity of helper T-lymphocytes) more common in whites, rare in developing countries onset may be abrupt or gradual Diverticulosis of Colon Features o Diverticula mucosal pouches forced outward through the circular muscle coat of the colon @ sites where branches of the mesenteric arteries penetrate the muscular coat & interrupt its continuity Lacks a muscularis propria Cannot empty itself Filled w/ a small inspissated lump of feces Located in subserosa of colon Almost always multiple o Pouch = 0.5-1 cm diameter w/ a small artery in its neck & arching over its dome o Diverticulosis condition w/ man diverticula; most causing no symptoms Location usu. restricted to sigmoid colon Cause exaggerated segmental contractions of the colon o Predisposing factors low fiber diet, obesity o Uncommon under age 40 Diverticulitis o Ulceration on the thin-walled diverticula sac by inspissated feces bacterial invasion perforation of deverticulum infection of perdiverticular tissue o Results in inflammation (acute &/or chronic) o Symptoms: Often asymptomatic Severe pain in lower left quadrant of abdomen Chronic extensive paracolic fibrosis; stenosis of sigmoid colon w/ constipation

Pathology Exam 3

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& left lower quadrant abdominal mass Hemorrhage into colon

Carcinoma of the Large Bowel Most common visceral cancer usu. in older adults Cause o Uncertain o Related to: refined, low residue, high fat diet seen in developed countries ( stool bulk, stool transit time, change bacterial flora possibly creating carcinogens from food) Precancerous lesions Characteristics Appearance Signs Adenomatous Benign granular tumors Small, pink, ovoid Asymptomatic polyps Often multiple Recurrent bleeding nodules enlarged Can mutate into malignant carcinoma bulky papillary Change in bowel habits Removed by colonoscopy masses Familial Autosomal dominant trait (chr. 5) Hundreds-thousands Diarrhea polyposis of Numerous adenomatous polyps of polyps Melena colon appear in 20s Death b/t 20-40 yrs old Malignant change occurs Chronic ulcerative colitis Chronic radiation proctocolitis Pathologic Anatomy o Distrubution: Rectum = 35% Sigmoid colon = 25% Remainder of colon = 40% (esp. in cecum & ascending colon) o Primary lesion: large annular tumor napkin ring tumor encircles most/all of bowel wall pinkish-gray, granular, firm polyploid (fungating cauliflower mass w/ superficial ulceration) OR sessile (infiltrative, deep ulcer w/ elevated nodular margins) often extends as deep as colonic serosa or perirectal tissue; can cause intestinal obstruction o Microscopic features: moderately differentiated adenocarcinoma; variable mucin production o Metastases: regional (mesocolic) lymph nodes first, then in liver, lungs, peritoneum Clinical Features o Constipation &/or diarrhea o Dull abdominal pain o Fresh or altered blood in stool o Anemia, weakness, wt. loss o Progressive lower intestinal obstruction Treatment

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o o o

Resection 5 year survival rate varies inversely w/ extent of tumor spread untreated pts live ~18 months after diagnosis